Provider Demographics
NPI:1558488460
Name:DIEGO-MEDINA, JACQUELINE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:
Last Name:DIEGO-MEDINA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:JACQUELINE
Other - Middle Name:
Other - Last Name:DIEGO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LMSW
Mailing Address - Street 1:294 MOUNTAIN VISTA RD.
Mailing Address - Street 2:
Mailing Address - City:LA UNION
Mailing Address - State:NM
Mailing Address - Zip Code:88021
Mailing Address - Country:US
Mailing Address - Phone:915-252-4174
Mailing Address - Fax:
Practice Address - Street 1:5001 N PIEDRAS ST
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79930-4210
Practice Address - Country:US
Practice Address - Phone:915-564-6100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-24
Last Update Date:2021-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX41732104100000X, 1041C0700X
NMM-05991104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial Worker